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When Diabetes Takes a Back Seat
Abstract & Commentary
By Allan J. Wilke, MD, Residency Program Director, Associate Professor of Family Medicine, University of Alabama at Birmingham School of MedicineHuntsville Regional Medical Campus, Huntsville. Dr. Wilke reports no financial relationship to this field of study.
Synopsis: The number, type, and severity of comorbidities are important determinants of diabetes self-care.
Source: Kerr EA, et al. J Gen Intern Med. 2007;22:1635-1640.
As physicians, we expect our patients to take an active role in the management of their chronic illnesses. In particular, we expect patients with diabetes to watch what they eat, poke themselves in their fingers several times daily, and take their medications. As daunting as this task may be, it's not difficult to imagine how much worse it would be with a second or third chronic illness to manage. In this study, Kerr and colleagues at the University of Michigan hypothesized that the number of comorbidities is insufficient to fully explain the effect of comorbidities on diabetes. They looked at the type and severity of comorbidities and their effect on how patients prioritize and self-manage their diabetes, using the Health and Retirement Study, sponsored by the National Institute on Aging, as their database. This database has information on more than 30,000 subjects. Of them, 2350 reported having diabetes, and 1900 completed a survey that provided more in-depth information about the disease. The respondents were 53% female and 76% white. Seventy percent (70%) were at least 65 years old, and 65% had at least a high school education. They were relatively well-off financially. The mean duration of diabetes was about 12 years.
The investigators looked at the comorbid chronic conditions the subjects reported, and classified them as "concordant" or "discordant" with diabetes. Concordant conditions included illnesses such as hypertension, retinopathy, and heart disease. They reasoned that these conditions shared the same pathophysiology as diabetes. These conditions were further subdivided into microvascular (retinopathy, neuropathy, and nephropathy) and macrovascular (cardiovascular disease, cerebrovascular disease, hypertension, and heart failure). Discordant diseases (pulmonary disease, cancer, and arthritis) were those that do not share diabetic pathophysiology. The importance that diabetic patients place on their illness, diabetes prioritization (DP), was scored with three questions: "Taking care of my diabetes is a top priority right now," "I have other health problems that are more important than diabetes," "I have many more important things in my life than diabetes to take care of right now." The second variable was diabetes self-management ability (SMA). The subjects were asked to rate their ability to attend to 5 areas: taking medication, exercising, meal planning, monitoring blood glucose, and foot examination with another scale that ranged from "so difficult I couldn't do it at all" to "not difficult, I got it exactly right." Finally, they focused on heart failure, a common comorbidity, and classified it as mild-to-moderate or severe.
Ninety-two percent (92%) of subjects had at least one comorbid condition; 25% had four or more. As the number of all comorbid conditions increased, the subjects' DP and SMA declined. However, when the investigators looked at DP by comorbidity subtype, microvascular conditions had no effect. Macrovascular conditions and discordant conditions were both associated with lower DP. Comorbidity subtype did not affect SMA; greater numbers of any subtype were associated with lower SMA. Looking specifically at heart failure, mild heart failure did not affect DP or SMA, but severe heart failure did.
Recently I participated in a seminar for family medicine chief residents. The topic was diabetes mellitus. I began my presentation by asking rhetorically for a show of hands of those residents who had a patient with diabetes and nothing else. No hands went up.
One thing I like about this study is its attempt to quantify the biopsychosocial model of medicine, so beloved by primary care physicians. Intuitively, I know that when I have two patients with a chronic illness, and one is mastering self-management and the other is not, I need to explore the context of the illness. What else is going on in his life? Does she have other illnesses? As our population ages, more and more of our patients will have not just one chronic illness. A few years ago, I was a co-author of a study that looked at several issues of self-management of diabetes from the patient's point of view. We conducted focus groups, and one of the participants said, "Well, I have so many things wrong that diabetes is not usually my primary concern...They got me a glucometer...but I had so much trouble... ya gotta get the blood right down on one particular spot. And I couldn't see it good enough, and I'd always get blood all over everything. And I'd get four or five of those strips in there and still wouldn't get an answer." Is it any wonder that self-management is so difficult!
What is the lesson here? It is to avoid "occulostenosis" when dealing with patients with diabetes. Osler said it best: "It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has." Specifically for diabetes, it means asking your patient whether his heart failure makes it difficult for him to exercise daily. Does her retinopathy prevent her from accurately drawing up her insulin? Who is the primary cook in the household? Does that person know the patient's dietary requirements? Is his arthritis so bad, he can't bend over to examine his feet or have the dexterity to use his glucometer? Of course, it's so much simpler to order a hemoglobin A1C, but with third-party payers scrutinizing our practices and pay-or-performance becoming a reality, simple is simply not good enough.